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16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017
| Contributor Information
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16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
This plain abdominal radiograph from a 3-year-old patient shows multiple metallic particles due to ingested flakes of lead paint.
When interpreting pediatric imaging studies, it is critical to be familiar with normal variations, anatomic deviations, normal bone appearance, and growth plate maturation, as well as pitfalls related to different imaging artifacts, in order to identify abnormal findings. See if you can correctly determine findings on the following pediatric images.
Image courtesy of Medscape.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
An unresponsive preschooler was brought to the emergency department with an unclear trauma history. Fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) of the brain was performed (shown).
What are the MRI findings and their possible causes?
Image courtesy of Medscape.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
Findings: Intrahemispheric subarachnoid bleeding (red arrows) with bilateral subdural hematomas (blue arrows) is present.
Child abuse should be suspected in trauma cases with a missing or unclear history, particularly those involving high-risk children. Patients considered to be at high risk include infants and preschoolers, as well as children with behavioral problems, developmental delays, physical and/or mental abnormalities, or other medical conditions. A skeletal survey should be requested whenever child abuse is suspected.[1]
Image courtesy of Medscape | Lawrence R. Ricci, MD.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
A child presented with a slap mark on the face, raising the concern for possible abuse.
The requested skeletal survey demonstrated consolidated radius and ulna fractures (yellow arrows).
Every year, more than 3 million reports of child abuse and neglect are made in the United States, involving more than 6 million children.[2] A study estimated the lifetime cost of 1 year of confirmed cases of child maltreatment in the United States to be $124 billion.[3,4]
Image courtesy of Medscape | Lawrence R. Ricci, MD.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
A skeletal survey of the same child in the previous slide also revealed multiple rib fractures (yellow arrows). Fractures that are highly specific for abuse include posterior rib fractures, as well as scapular and spinous process fractures. Fractures with different healing stages also have high specificity for abuse. These findings should mandate reporting to child protective services.
An average of more than four children per day die as a result of child abuse or neglect in the United States.[5] In 2015, an estimated 1670 children died as a consequence of child abuse or neglect.[5]
Image courtesy of Medscape.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
Findings: Shown is a computed tomography (CT) scan that reveals a lacerated liver in a child who suffered repeated punches to the abdomen.
Image courtesy of Medscape.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
Question: What is the syndrome revealed in the MRI shown? What is the role of MRI in this syndrome?
Image courtesy of Medscape.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
Answer: Tethered cord syndrome
The MRI reveals a low-lying conus below the level of L2 (red arrow), which is associated with anatomic abnormalities such as an intradural sacral lipoma/tethered cord (blue arrow). In these types of cases, MRI may aid in surgical decision making.[6]
Image courtesy of Medscape.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
This abdominal CT scan is from a child with a history of blunt abdominal trauma. What is the most common diagnosis based on the CT scan and the patient's history?
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16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
Answer: Pancreatic pseudocyst
The CT scan in the region of the pancreas demonstrates a large, well-marginated cystic structure that is a pancreatic pseudocyst. The differential diagnosis includes a large choledochal cyst. The pseudocyst, a fibrous-walled cavity filled with pancreatic enzymes that complicates pancreatitis, is primarily localized in the lesser sac behind the stomach. The incidence of pancreatic pseudocysts is greater than 50% when associated with traumatic injury to the abdomen. As a result of limited case reporting and underdiagnosis by clinicians, the frequency and true incidence of pancreatitis in children is unknown. Trauma is responsible for an estimated 10-40% of pediatric cases of acute pancreatitis.[6,7]
Image courtesy of Medscape.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
This CT scan shows a large type I choledochal cyst and the gallbladder, adjacent to it. Note that the cyst is typically filled with bile, which produces waterlike attenuation. If any question concerning the diagnosis remains after a CT scan, endoscopic retrograde cholangiopancreatography (ERCP) can be performed.
Image courtesy of Medscape.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
This technetium-99m pertechnetate scan was performed on a 12-year-old boy with right lower abdominal pain and rectal bleeding. Neither appendicitis nor intussusception was found on ultrasonography. What is the diagnosis?
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16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
Answer: Meckel diverticulum
The delayed image shows focal activity in the right lower quadrant. An inflamed Meckel diverticulum containing ectopic gastric mucosa was removed during surgery.
Image courtesy of Medscape | Mark V Mazziotti, MD.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
This CT scan was obtained in a child with right lower abdominal pain. There were no abnormal ultrasonographic findings due to intestinal interposition. What does the CT scan reveal?
Image courtesy of Medscape | Mark V Mazziotti, MD.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
Answer: A distended, ovoid structure descending into the pelvis and containing a central, round calcification (appendicolith) (arrow)
Acute appendicitis is one of the most common causes of abdominal pain, and it is the most frequent condition leading to emergency abdominal surgery in children. A delay in the diagnosis is associated with rupture and other complications, especially in young children. Ultrasonography is often the first imaging modality used in pregnant and pediatric patients with abdominal pain. Its advantages include an absence of radiation exposure and a short acquisition time, as well as the potential ability to identify and diagnose other causes of abdominal pain.
Image courtesy of Medscape.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
A child presented with recurrent urinary tract infections. Ultrasonography was performed as recommended. The first study demonstrated bilateral hypoechoic areas with thinning of the renal parenchyma (shown). What diagnoses should be considered?
Image courtesy of Medscape.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
Answer: Renal cysts and/or hydronephrosis
This longitudinal ultrasonogram of the right kidney shows that the hypoechoic areas interconnect (arrow), a finding that is consistent with hydronephrosis rather than with multiple distinct renal cysts, which do not interconnect. What imaging study is indicated next?
Images courtesy of Medscape.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
Answer: Voiding cystourethrogram
The ultrasonographic findings may be due to complications of a posterior urethral valve. Voiding cystourethrographic evaluation of the abdomen, bladder, and urethra confirmed the presence of the posterior urethral valve (left) and demonstrated a trabeculated bladder, diverticula, and bilateral massive reflux (right).
Image courtesy of Medscape | Robert Cirillo, MD.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
This angiogram was performed on a 10-year-old girl with headaches. What are the indication, findings, and diagnosis suggested by this image?
Image courtesy of Medscape | Robert Cirillo, MD.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
Indication: More than 50% of patients who present with headache, blood pressure differences in the extremities, claudication, arthralgia, and/or bruit (most commonly at the carotid artery) have arteritis of the great vessels.[8]
Findings: Narrowing of the proximal descending aorta (blue arrow) and right brachiocephalic artery (red arrow) are present.
Diagnosis: Takayasu arteritis is the only form of aortitis that causes stenosis and occlusion of the aorta. Fibromuscular dysplasia is a differential diagnosis for Takayasu arteritis.[9] However, fibromuscular dysplasia usually does not affect the aorta, and it is rare in the subclavian artery. Ninety percent of patients with Takayasu arteritis are younger than 30 years,[9] and most of them are female.[10]
Image courtesy of Medscape.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
This frontal chest radiograph is from a newborn presenting with early respiratory distress. What are the findings and diagnosis suggested by this image?
Image courtesy of Medscape.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
Findings: Herniation of the liver (white arrow) and bowel loops into the right hemithorax (yellow arrow), as well as a shift of the heart and mediastinum to the left side (green arrow), can be seen on the radiograph.
Diagnosis: This is a right-sided congenital diaphragmatic hernia. Loss of the normal well-delineated right superior curvilinear diaphragmatic contour (black arrow) and the shifted mediastinum help to distinguish this condition from others in the differential diagnosis, such as congenital cystic adenomatoid malformation.
Image courtesy of Medscape.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
This chest radiograph is from another newborn presenting with early respiratory distress. What are the findings that would lead to the correct diagnosis?
Image courtesy of Medscape.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
Findings: Physiologic fluid was reabsorbed from an area of congenital cystic adenomatoid malformation and replaced with an air-containing cystic area that occupies the right upper lung (yellow arrow). Note the well-defined right diaphragmatic line that helps to distinguish this finding from herniation (black arrow).
Diagnosis: Congenital cystic adenomatoid malformation is a developmental hamartomatous abnormality of the lung, with adenomatoid proliferation of cysts resembling bronchioles.[11]
Image courtesy of Medscape | Brit B. Gay, Jr, MD.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
A child presented with a 2-month history of wheezing. What is the main finding on this radiograph?
Image courtesy of Medscape | Brit B. Gay, Jr, MD.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
This radiograph, obtained during an exhale, is from the same child as in the previous slide. Note the hyperlucency and hyperexpansion of the right hemithorax that were also present in slide 25. A greater mediastinal shift is noted toward the left lung field. What is the most likely diagnosis based on these findings?
Image courtesy of Medscape.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
Answer: Foreign body aspiration
The patient in slides 25 and 26 had a corn kernel removed from their right mainstem bronchus during bronchoscopy.
This radiograph is from another child with the same clinical condition as the child in the previous two slides. It shows a radiopaque earring backing (arrow) lodged in the right mainstem bronchus. Aspirated foreign bodies are most often found in pediatric patients, and they account for thousands of US emergency department visits annually.[11] Clinicians must therefore maintain a high index of suspicion for airway foreign body aspiration in young patients to allow prompt treatment, as well as to avoid its complications. Estimates of deaths from foreign body aspiration range from hundreds to thousands,[11-13] with most deaths occurring before hospital evaluation and treatment.[13]
The most common site of airway foreign bodies is the right mainstem bronchus due to its posterior location, shallow angle to the trachea, and wide diameter. The density of the aspirated item will determine whether or not it can be directly identified on radiographs. Indirect signs of airway foreign body used to confirm the diagnosis include ipsilateral focal overinflation if there is partial obstruction or ipsilateral atelectasis if a more complete obstruction is present.[13]
Image courtesy of Medscape | Kelly Marshall, MD, Scottish Rite Hospital, Children's Healthcare of Atlanta.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
This radiograph is from an infant with abdominal pain and vomiting. What should be suspected?
Image courtesy of Medscape | Kelly Marshall, MD, Scottish Rite Hospital, Children's Healthcare of Atlanta.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
Answer: Intussusception
Note the small bowel obstruction pattern, with crescent sign to the left upper quadrant; these findings should always indicate the diagnosis of intussusception. Unfortunately, in plain abdominal radiography, up to 40% of cases have no signs that suggest this diagnosis. However, evaluation can also be made by ultrasonography.[14]
Image courtesy of Medscape.
16 Can’t-Miss Findings on Pediatric Imaging Studies
José Luiz de Oliveira Schiavon, MD, MSc | August 3, 2017 | Contributor Information
This ultrasonogram reveals the classic target sign of an intussusception case. Ultrasonography has almost 98% sensitivity and specificity for this important diagnosis, which should be treated immediately by therapeutic enema or surgical reduction.[15,16]
Understanding the "Hidden Pediatric Problem": Sexual Abuse
Child sexual abuse is a global underrecognized and underreported problem. Learn how to diagnose and evaluate suspected victims of sexual abuse, as well as understand some key considerations when managing these patients.Slideshows, June 2017
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Contributor Information
Author
José Luiz de Oliveira Schiavon, MD, MSc
Associate Professor
Department of Pediatric Radiology
Instituto de Oncologia Pediatrica
Universidade Federal De Sao Paulo
Sao Paulo, Brazil
Disclosure: José Luiz de Oliveira Schiavon, MD, MSc, has disclosed no relevant financial relationships.
Reviewer
David S Levey, MD
Diagnostic Radiology
Bone Imaging/Musculoskeletal
Paesanos Parkway Imaging
San Antonio, Texas
Disclosure: David S Levey, MD, has disclosed no relevant financial relationships.
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References
Giardino AP, Giardino ER, Moles RL. Physical child abuse: Medscape Drugs & Diseases from WebMD. Updated: April 24, 2017. Available at: http://emedicine.medscape.com/article/915664-overview. Accessed: July 20, 2017.
Fang X, Brown DS, Florence CS, Mercy JA. The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse Negl. 2012 Feb;36(2):156-65. PMID: 22300910
Injury Prevention & Control: Division of Violence Prevention. Cost of Child Abuse and Neglect Rival Other Major Public Health Problems. Centers for Disease Control and Prevention. January 14, 2014. Available at: http://www.cdc.gov/violenceprevention/childmaltreatment/economiccost.html. Accessed July 20, 2017.
US Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau. Child Maltreatment 2015. Washington, DC: HHS; January 19, 2017. Available at: https://www.acf.hhs.gov/cb/resource/child-maltreatment-2015. Accessed July 20, 2017.
Barkovich AJ, Moore KR, Grant PE, et al, eds. Diagnostic Imaging: Pediatric Neuroradiology. Salt Lake City, UT: Amirsys Publishing, Inc; 2007.
Kim IA, Shapiro N, Bhattacharyya N. The national cost burden of bronchial foreign body aspiration in children. Laryngoscope. 2014 Nov 1. PMID: 25363312
De Cecco CN, Bellini D, Muscogiuri G, et al. Diseases of the Colon and Rectum. In: Saba L, Suri JS eds. Multi-Detector CT Imaging: Abdomen, Pelvis, and CAD Applications. Boca Raton, FL: CRC Press; 2013: 213-31.
Henderson AA, Anupindi SA, Servaes S, et al. Comparison of 2-view abdominal radiographs with ultrasound in children with suspected intussusception. Pediatr Emerg Care. 2013 Feb;29(2):145-50. PMID: 23364378
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